PsychoPharm 102 ADHD and Dopamine-Norepinephrine-Serotonin
PsychoPharm 102 The basics of serotonin, dopamine and norepinephrine in ADHD
Basic premise: Build up dopamine and norepinephrine and try not to increase serotonin.
Why do I have to know about serotonin, dopamine and norepinephrine?
Different medications have varying effects on these three brain neurotransmitters , serotonin, dopamine and norepinephrine. Understanding the underlying brain chemistry problem and what medications can help it is the first step in picking a medication and educating the patient. ADHD is such a disorder and usually straight forward to explain and treat.
What does ADHD have to do with these brain chemicals?
The simplest mental health disorder biochemically to explain is Uncomplicated Classical ADHD or Attention Deficit Hyperactivity Disorder believed to be caused by not having enough dopamine primarily and secondarily norepinephrine. Medications that increase these brain chemicals should help the three core symptoms of hyperactivity, inattention and impulsivity. Other forms of ADHD may have different brain chemistry causes and is discussed elsewhere. Dr. P Discussion and Views on ADHD, ADHDtheDiagnosis, ADHD Fact Sheet, Meds or not for ADHD, ADHD and Meditation
What are the classes of medication that may help ?
The three classes that work on building up dopamine and norepinephrine are the neurostimulants, certain antidepressants, and medicines originally used for high blood pressure clonidine and gaunfaciene.
Why do you say certain antidepressants?
Because most antidepressants that are used today work strongly on serotonin, and for many people anything that builds up serotonin may decrease alertness, attention, concentration and short term memory. So one would want to avoid these medications ,especially Prozac, Paxil, Zoloft, Celexa, Lexapro, Luvox. Of questionable usefulness are Effexor and Cymbalta because of their effects on norepinephrine. The useful antidepressants include the newer ones Welbutrin and Strattera, but also older tricylic ones like imipramine -desipramine or nortryptilene. The specifics of using antidepressants will be further discussed under its own heading.
What are the implications of this for developing a biochemical profile and diagnosis?
Avoid or use minimally medications that have an effect on serotonin, and maximize medications that work preferentially on dopamine and norepinephrine. The medications that do this the most are the neurostimulants, and the ones that do these the least are the antidepressants that work preferentially on serotonin.
What is the medication of choice and are there any differences between them as far as neurotransmitters?
The medications of choice for seventy years have been the neurostimulants[ Adderal, Dexedrine, Focalin, Ritalin, Metadate, Concerta, Daytrana, Vyvanse ], that build up dopamine and norepinephrine. Though they all basically work the same, but there are individual differences based on ones unique brain chemistry. Adderal, Dexedrine, and Vyvanse are amphetamine based and tend to be more stimulating which could lead to activation and nervousness, perhaps because they work strongly on dopamine and norepinephrine, where as the methylphenidate products , Ritalin, Concerta, Daytrana, Methylin work more so just on dopamine, but the draw back with this is that rather than being activating, it can slow down too much giving a stoned or drugged effect. Focalin which is a derivative of methylphenidate, its right handed version tends to work intermediate between these extremes of activation and being too slow down. ADHD-Stimulant Medications-Intro Q and A
What does one do practically in picking a stimulant?
They are all equally effective, first go by family or personal history , if there has been a good response to a specific product try that first. If it gives activation or make the person too slowed down, try a product from the other category. Focalin may be a good place to start because its side effect profile tends to be in the middle but there are many exceptions to this. Use trial and error to find the stimulant that does the job without causing too many negative effects. If there are too many side effects after trying different medications and dosing schedules , then try another class by itself or with a lower dose of the stimulant.
How do you explain this to the patient or their family?
I start out be explain that ADHD is disorder of dopamine-norepinephrine , the brain needing more of these chemicals, and that we have three classes of medication, and we will start with the safest ones that have the best track record the stimulants. The stimulants have about 85 to 95% efficacy, the anti depressants perhaps 60 to 70%, and clonidine and gaunfaciene usually much less effective for concentration directly, but helps greatly at times for the over activity and impulsivity components of ADHD. Sometimes we use these classes together, and I emphasize the roles they play on the brain chemistry and how we have to fine tune whatever medication we use based on the individual good or negative effects of the medicine.